Medical Records Director
2 days ago
We are seeking a highly skilled and experienced Medical Records Director to join our team at PACS Inc. The successful candidate will be responsible for overseeing the medical records department, ensuring accurate and timely processing of medical records, and maintaining confidentiality and security of patient information.
Key Responsibilities- Oversee the daily operations of the medical records department, including receiving, processing, and storing medical records.
- Ensure compliance with federal and state regulations, as well as facility policies and procedures, regarding medical records management.
- Develop and implement policies and procedures for medical records management, including record retention and destruction.
- Supervise and train medical records staff, including coding and indexing of medical records.
- Collaborate with other departments, such as nursing and administration, to ensure seamless communication and coordination of medical records.
- Develop and maintain a good working rapport with interdepartmental personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.
- Assist in recording all incidents/accidents and file in accordance with established policies and procedures.
- Retrieve resident records (manually/electronically) and deliver as necessary.
- Files information such as nurses' notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.
- Collect, assemble, check, and file resident charts as required.
- Assist MDS Coordinator in scheduling assessments in accordance with current facility and OBRA guidelines.
- Ensure incomplete records/charts are returned to appropriate departments or personnel for correction.
- Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, etc., before filing.
- Maintain a record of authorized information released from charts/records, i.e., type information, name of recipient, date, department, etc.
- Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc. in accordance with current Privacy Rules.
- Index medical records as directed by the medical records/health information consultant.
- Maintain various registries as directed, including register for admission and discharge of residents.
- Transcribe and type reports for physicians as necessary.
- Collect charts, assemble them in proper order, and inspect them for completion.
- Pick up and deliver resident medical records from wards, nurses' stations, and other designated areas as necessary.
- Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.
- Answer telephone inquiries concerning medical records functions.
- Prepare written correspondence as necessary.
- Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies, and personnel, etc.).
- Assure that medical records taken from the department are signed out and signed in upon return to the department.
- File active and inactive records in accordance with established policies.
- Index medical records as directed.
- Must possess, as a minimum, a high school diploma or GED.
- Must be able to type a minimum of 45 words per minute and use dictation equipment.
- A working knowledge of medical terminology, anatomy, and physiology, legal aspects of health information, coding, indexing, etc., preferred but not required.
- On-the-job training provided in medical record and health information system procedures.
- Must be knowledgeable of medical terminology.
- Be knowledgeable in computers, data retrieval, input, and output functions, etc.
- Must be able to read, write, speak, and understand the English language.
- Ability to read technical procedures.
- Mathematical skills to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
- Reasoning ability to make independent decisions when circumstances warrant such action.
- Ability to deal tactfully with personnel, residents, visitors, and the general public.
- Ability to work harmoniously with other personnel.
- Ability to minimize waste of supplies, misuse of equipment, etc.
- Ability to seek out new methods and principles and be willing to incorporate them into existing practices.
- Ability to follow written and oral instructions.
- Must not pose a direct threat to the health or safety of other individuals in the workplace.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Works in office areas as well as throughout the facility. Moves intermittently during working hours. Is subject to frequent interruptions. Works beyond normal working hours, weekends, and holidays and on other shifts/positions as necessary. Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.). Attends and participates in continuing educational programs. Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants. Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses. Communicates with nursing personnel, and other department personnel. Is subject to hostile and emotionally upset residents, family members, personnel, visitors, etc. Is involved with residents, family members, personnel, visitors, government agencies, and personnel, etc., under all conditions and circumstances. May be subject to the handling of and exposure to hazardous chemicals.
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